Robotic Prostatectomy - How to Decide and What Actually Determines Your Result

A surgeon’s guide for men who already have a prostate cancer diagnosis

By Dr Dharmender Aggarwal

Senior Consultant — Urology, Uro-Oncology & Robotic Surgery, Fortis Hospital, Mohali

MCh Urology (PGIMER, Chandigarh)  | Fellowship in Robotic Surgery & Uro-Oncology, Royal College of Surgeons of England (St George’s University Hospital NHS Trust)  |  ERUS certified  |  ORSI certified  |  950+ robotic cancer surgeries  |  Proctor and trainer for robotic urology programs

Almost every man who sits across from me after a prostate biopsy asks the same question in the first two minutes: “Doctor, is the robotic one better?”

It is the wrong first question, and I say so gently. The honest sequence is: should you be operated on at all, and if yes, by whom, and with what technique. The platform comes fourth on that list, not first. What follows is how I work through those questions in my clinic, including the parts that hospital marketing usually leaves out.

Start by reading your own biopsy report

Most patients arrive having read the word “cancer” and nothing else on the page. Three numbers on that report, plus your scan, decide almost everything that follows.

• The Gleason score / ISUP Grade Group. Reported as two numbers added together, for example 3+4=7. The first number is the dominant pattern. Grade Group 1 (Gleason 6) behaves very differently from Grade Group 4 or 5. A 3+4 and a 4+3 are both “Gleason 7” and are not the same disease.
• Your PSA level. Not just the number, but how it has moved over time if you have earlier readings.
• The number and percentage of cores involved. How much of the gland the disease occupies matters as much as its grade.
• The clinical and radiological stage. From your examination and, ideally, a multiparametric MRI reported using PI-RADS.

Together these place you in a risk category — low, intermediate (favourable or unfavourable), or high risk. That category, not the availability of a robot, is what should drive your treatment discussion. For high-risk disease we now also use PSMA PET-CT, which detects nodal and distant spread more accurately than conventional CT and bone scan and occasionally changes the plan entirely.

Surgery is one of three legitimate options, not the default

I am a robotic surgeon. It would be easy for me to write that surgery is the answer. The evidence does not allow me to.

The ProtecT trial randomised 1,643 men with PSA-detected localised prostate cancer to active monitoring, radical prostatectomy or radiotherapy. At 15 years of follow-up, published in the New England Journal of Medicine in 2023, death from prostate cancer was low across all three arms — 3.1%, 2.2% and 2.9% respectively — with no statistically significant difference between them.

What did differ was progression. Metastases developed in 9.4% of the monitoring group compared with 4.7% after surgery and 5.0% after radiotherapy, and clinical progression in 25.9%, 10.5% and 11.0% respectively. Nearly a quarter of the men on monitoring were still alive at the end of follow-up without having had any prostate cancer treatment at all. However, around 3/4th of the people did require some treatment in future. 

What this means for you: for genuinely very low-risk disease, immediate radical treatment may buy you little while costing you continence and erections. For intermediate and high-risk disease, radical treatment substantially reduces the chance of the cancer spreading. The trade-off is real, it runs in both directions, and it is yours to weigh with your doctor — not something a hospital should decide for you. But the decision of low risk does not fall only on gleason score, it uses all parameters of cores, PSA, and MRI findings.

So in my clinic, active surveillance with structured MRI and PSA follow-up is offered, and taken up, for suitable very low-risk patients. Radiotherapy with a radiation oncologist is a genuine alternative and I say so. Radical prostatectomy is what I recommend when the cancer is significant enough to justify it and you are fit enough to benefit from a durable, single-episode treatment with a pathology report at the end of it that tells us exactly what we were dealing with. Surgery all gives hope for long term recovery without significant long term complications but it needs extra efforts from surgeon as well as patient during and early post-operative time. 

What the robot changes — and what it does not

This is where I depart from a lot of what is written about robotic surgery.

The first randomised controlled trial comparing robot-assisted with open radical prostatectomy, reported by Yaxley and colleagues in the Lancet in 2016 and followed to 24 months by Coughlin and colleagues in Lancet Oncology in 2018, found similar urinary and sexual function outcomes between the two approaches, and no significant difference in imaging evidence of progression. The investigators concluded that the benefits of the robotic approach should be viewed as being largely related to its minimally invasive nature.

I quote that finding to patients deliberately, because it corrects a misconception that costs people money and expectation. The robot is a superb instrument. It is not, on its own, a better outcome.

What it does give

• Substantially less blood loss and a very low transfusion requirement.
• A short stay and a fast return to routine — typically day-of or next-day mobilisation, catheter for around a week, desk work within three to four weeks.
• Ten-times magnified 3D vision at depth, which is where the neurovascular bundles run and where the difference between a good and an indifferent nerve-sparing dissection is made.
• Tremor-filtered, fully wristed instruments for the urethra-vesical anastomosis and the apical dissection — the two technical steps most closely linked to continence. Bladder neck sparing and nerve sparing dissection which allows faster continence recovery is also impacted by magnified vision of robotic system.

What it does not give

• It does not remove more cancer than a good open surgeon would. The specimen is the same specimen.
• It does not compensate for low volume. Prostatectomy has one of the steepest learning curves in surgery, and the association between surgeon volume and both margin status and functional recovery is one of the most consistent findings in the literature. Choosing a high volume surgeon who does same surgery multiple times in a week is more important. 
• It does not guarantee nerve-sparing. Whether the bundles can be spared, and how much, is decided by where the tumour sits, disease grade and its stage and experience of the surgeon not only by the robotic equipment.

The three outcomes we are balancing at the console

Every decision I make during a prostatectomy is a trade-off between three things. Surgeons sometimes call achieving all three the “trifecta”.

1. Cancer clearance — negative surgical margins and, where indicated, an adequate pelvic lymph node dissection.
2. Urinary continence — protecting the external sphincter, the apex, the fascia and the supporting structures around the urethra.
3. Erectile function — preserving the neurovascular bundles where oncologically safe to do so.

These pull against each other. Aggressive nerve-sparing in a man whose tumour is close to the capsule risks a positive margin. Over-cautious dissection in a man with organ-confined disease costs him function he did not need to lose. The judgement call is made personally for every patient, in the moment, on the anatomy in front of me, informed by the MRI and the biopsy map. This is the part of the operation that no platform performs for you.

Technique choices that make a measurable difference

• Grade of nerve-sparing. Nerve-sparing is not binary. It is graded, and the plane is chosen side by side depending on where the disease sits on that side.
• Retzius-sparing (posterior) approach. By approaching the prostate from behind and leaving the anterior supporting structures undisturbed, early continence recovery is faster. In a randomised trial reported in European Urology in 2017, 71% of men in the Retzius-sparing arm were continent one week after catheter removal compared with 48% in the standard arm, with comparable complication and biochemical recurrence-free outcomes. It is technically harder and it is not suitable for every tumour, particularly some anterior and high-risk cases.
• Bladder neck preservation and precise apical dissection. Both are associated with earlier return of continence and both depend entirely on visualisation, instrument control, and surgeon’s experience.
• Pelvic lymph node dissection in intermediate-unfavourable and high-risk disease, guided by nomogram risk of nodal involvement.

A realistic recovery timeline

I would rather you have accurate expectations than optimistic ones. This is what a typical uncomplicated course looks like; individual recovery varies with age, baseline function, nerve-sparing grade and final pathology.

Two things I insist on: pelvic floor training starts before surgery, not after the catheter comes out; and if the final pathology shows adverse features, we discuss further treatment promptly rather than waiting for the PSA to climb.

Myth vs Fact

Questions worth asking any surgeon before you consent

I would encourage you to ask these of me, and of anyone else you consult. A surgeon who is comfortable with the answers will not mind the questions.

Why Fortis Hospital, Mohali

If surgeon and program volume is the variable that matters most, then the case for a centre has to be made on exactly that basis rather than on the equipment in the theatre.

• An Intuitive Total Program Observation site. Fortis Mohali has been designated by Intuitive Surgical as India’s second Total Program Observation (TPO) site, and the first outside a metro city. TPO sites host visiting surgical teams from other institutions who come specifically to observe an established robotic program at work. That is an external assessment of the program, not a claim we make about ourselves.
• Two da Vinci Xi systems. The fourth-generation platform, with a second console added to support the volume of the program across specialties.
• Surgeon volume and teaching role. Dr Dharmender Aggarwal have performed over 950 robotic cancer surgeries of the prostate, kidney, bladder and upper urinary tract, trained through the Royal College of Surgeons of England, and he proctor surgeons establishing robotic programs at other hospitals. Teaching an operation forces a standard of consistency on the way you perform it. He is a senior consultant with dedicated approach to Urology cancer cases and a high-volume robotic surgeon performing and dealing with largest number of Prostate cancer cases in northern India. 
• The pathway around the operation. Multiparametric MRI and PSMA PET-CT, uro-pathology reporting, a multidisciplinary tumour board with radiation and medical oncology, dedicated Uro-oncology nursing, and pelvic floor physiotherapy that begins before surgery rather than after it.
• Honest counselling. Including telling you when I think you should be considering surveillance or radiotherapy instead. Patients travel to us from across Punjab, Haryana, Himachal Pradesh and Jammu & Kashmir, and they deserve the same conversation I would want for my own family. Dr Aggarwal specialises in personal focus and providing your case specific details and forming a treatment plan for specific case scenario instead of a generic advise of just performing surgery. 

Bring your reports, not just your worry

If you have a positive prostate biopsy, or you have been advised surgery and want a second opinion before you consent, come and see us. Please bring:

• Your biopsy histopathology report and records
• Multiparametric MRI images on disc, not only the report
• All PSA values you have, with dates — the trend matters
• Any PSMA PET-CT or bone scan already done
• Your list of medications and other medical conditions

Reviewing the actual images and slides tells me far more than a summary letter does, and it is often the difference between a general discussion and a specific plan.

Book a uro-oncology consultation

Dr Dharmender Aggarwal — Urology, Uro-Oncology & Robotic Surgery

Fortis Hospital, Sector 62, Phase VIII, Mohali, Punjab

Call 72728 72728

A prostate cancer diagnosis rarely requires a decision this week. It always deserves a properly informed one.

About the author

Dr Dharmender Aggarwal is Senior Consultant — Urology, Uro-Oncology and Robotic Surgery at Fortis Hospital, Mohali. He completed his MCh in Urology from PGIMER, Chandigarh, followed by fellowship training in robotic surgery and uro-oncology through the Royal College of Surgeons of England at St George’s University Hospital NHS Trust. He is ERUS and ORSI certified in robotic urological surgery, has performed over 950 robotic cancer operations of the prostate, kidney, bladder and upper urinary tract, and proctors surgeons establishing robotic programs at other institutions. His clinical focus is robotic uro-oncology and complex urinary reconstruction. He has dedicated focus on urological cancers and deals with largest number of prostate cancer and kidney cancer cases in northern India.